<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket>
<wicket:panel>
    <fieldset>
        <form wicket:id="form" class="form-horizontal">
            <div class="row-fluid">
                <div class="span6">
                    <div class="control-group">
                        <div class="control-label">Ingevoerde AGB-code</div>
                        <div class="controls value">
                            <span wicket:id="agbcode">123456789</span>
                        </div>
                    </div>
                    <div class="control-group">
                        <div class="control-label">AGB status</div>
                        <div class="controls">
                            <span wicket:id="agbStatus"></span>
                        </div>
                    </div>
                </div>
            </div>
            <hr>
            <div class="row-fluid">
                <div class="span6">
                    <div class="control-group">
                        <label class="control-label">Aanhef</label>
                        <div class="controls">
                            <select wicket:id="organisatieMedewerkers[0].medewerker.aanhef">
                                <option selected disabled>- Maak een keuze -</option>
                                <option>Dhr.</option>
                                <option>Mevr.</option>
                            </select>
                        </div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Achternaam</label>
                        <div class="controls">
                            <input class="input-large" type="text"
                                   wicket:id="organisatieMedewerkers[0].medewerker.achternaam">
                        </div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Tussenvoegsel</label>
                        <div class="controls">
                            <input class="input-mini" type="text"
                                   wicket:id="organisatieMedewerkers[0].medewerker.tussenvoegsel">
                        </div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Voorletter(s)</label>
                        <div class="controls">
                            <input class="input-mini" type="text"
                                   wicket:id="organisatieMedewerkers[0].medewerker.voorletters">
                        </div>
                    </div>
                    <div class="control-group">
                        <div class="control-label">E-mailadres (geen zorgmail)</div>
                        <div class="controls">
                            <input class="input-large" wicket:id="email" type="text"/>
                        </div>
                    </div>
                </div>
                <div class="span6">
                    <p>Dit is het adres is waar het registratieformulier van de huisarts naar toe gaat.</p>
                    <div class="control-group">
                        <div class="control-label">Straatnaam</div>
                        <div class="controls">
                            <input class="input-large praktijkadres straat" wicket:id="postadres.straat"
                                   type="text"/>
                        </div>
                    </div>
                    <div class="control-group">
                        <div class="control-label">Huisnummer + toevoeging</div>
                        <div class="controls">
                            <input class="input-small praktijkadres huisnummer" wicket:id="postadres.huisnummer"
                                   type="text"/> <input class="input-mini praktijkadres huisnummerToevoeging"
                                                        wicket:id="postadres.huisnummerToevoeging" type="text"/>
                        </div>
                    </div>
                    <div class="control-group">
                        <div class="control-label">Postcode</div>
                        <div class="controls">
                            <input class="input-large praktijkadres postcode" wicket:id="postadres.postcode"
                                   type="text"/>
                        </div>
                    </div>
                    <div class="control-group">
                        <div class="control-label">Plaats</div>
                        <div class="controls">
                            <select wicket:id="postadres.woonplaats"/>
                        </div>
                    </div>
                </div>
            </div>
            <hr>
            <div class="form-actions btn-bottom">
                <button class="btn btn-primary pull-right" wicket:id="uitnodigingVersturen">Verstuur aanvraag registratie</button>
                <button class="btn pull-right" wicket:id="annuleren">Annuleren</button>
            </div>
        </form>
    </fieldset>
</wicket:panel>
</html>
